Policy #<insert number here>
X-ray Operator Services Policy
Policy Statement
Queensland Health will maintain the provision of a high quality, limited x-ray service throughout
rural and remote Queensland.
Intent of this policy
To ensure a standardised approach to the provision of a safe and effective x-ray operator
service throughout rural and remote Queensland.
Scope
This policy applies to all Queensland Health employees involved in the provision of medical
imaging services delivered by x-ray operators (XOs) in Queensland Health.
Principles
The following principles shall guide the implementation of the X-ray Operator Services Policy:
 Appointment of XOs shall occur only in rural and remote facilities
 Maintain and improve the x-ray operator services through appropriate support and
training processes
 Ensure the equal access to safe, timely and sustainable x-ray services
 Maximise employee morale
 Promote continuous quality improvement of x-ray operator services
 Provide clear governance surrounding x-ray operator services
Legislative or other Authority
Radiation Safety Act 1999
Radiation Safety Regulation 2010
Related Policy or Documents
On Call Practices – Rural and Remote Medical Imaging Radiographers policy B63 (2010)
Radiation Safety Act 1999 – Application and Licence Fees – ‘Use’ Licences policy C33 (2009)
Allowances Policy C15 (2010)
Facility specific Radiation Safety and Protection Plan
Code of Practice for Radiation Protection in the Medical Applications of Ionizing Radiation
(2008)
Safety Guide for Radiation Protection in Diagnostic and Interventional Radiology (2008)
Diagnostic Imaging Accreditation Scheme (DIAS) for practices providing radiology and nonradiology services under Medicare – Stage II Standards
Version No.: 12.0; Effective From: <date>
<insert information security classification>
Page 1 of 5
Printed copies are uncontrolled
Queensland Health: X-ray Operator Services Policy
Supporting Documents
Queensland Statewide Health Services Plan 2007–2012
Queensland Health X-ray Operator Services Implementation Standard (2012)
Queensland Health X-ray Operator Services Staffing Guideline (2012)
Clinical Services Capability Framework for public and licensed private health facilities version
3.0 (CSCF v3)
Review
This policy will be reviewed at least every three years.
Date of Last Review: Nil
Supersedes: Guidelines for Licensed Operators – Employment, Education and Support policy
G20 (2010)
Approval and implementation
Policy Custodian
Mr Paul Carroll, Senior Director, Radiology Support
Responsible Executive Management Team member
Ms Kathy Byrne, CEO, Clinical and Statewide Services
Approving Officer:
Approval Date:
Effective from:
Definitions of terms used in this policy and supporting documents
Term
Definition/Explanation/Details
Source
Authorised persons
The person in the position which has the authority to request
a diagnostic procedure stated within schedule 6 of the
Radiation Safety Act 1999.
Queensland parliament
http://www.legislation.ql
d.gov.au/LEGISLTN/CU
RRENT/R/RadiatSafyR
10.pdf
Certificate of Competency
Document required for licence application. It provides
evidence of the certification of practical skill competence.
Clinical Services
Capability Framework
(CSCF v3)
The Clinical Services Capability Framework for public and
licensed private health facilities (or CSCF) serves to provide a
standard set of capability requirements for most acute and
sub-acute health facility services provided in Queensland by
public and private health facilities. Also it provides a
consistent language for health care providers and planners to
use when describing health services and planning service
developments.
Version No.: 12.0; Effective From: <date>
<insert information security classification>
Radiation Health
Queensland Health
Clinical Services
Capability Framework
for Public and Licensed
Private Health Facilities
version 3.0 – Medical
Imaging Services
http://qheps.health.qld.g
Page 2 of 5
Printed copies are uncontrolled
Queensland Health: X-ray Operator Services Policy
Term
Definition/Explanation/Details
Source
ov.au/pcb/docs/cscf_v3/
6_medicalimaging.pdf
Competency
Is a knowledge or skill which is performed to a specific
standard under specific conditions.
In terms of x-ray operators: Competency is the specific
standard in which radiographic knowledge or skill is
demonstrated to meet the requirements for a use licence
issued under the Radiation Safety Act.
Designated radiographer
A licensed diagnostic radiographer who provides support,
training or advice to an XO on behalf of their regular
radiographic advisor.
District Director of Medical
Imaging (DDMI)
Director responsible for the medical imaging services within
the health service district. In the absence of a DDMI, the
senior radiographer assumes the DDMI responsibilities for the
purposes of this policy.
Endorsed course
A course which has been assessed and approved by the
Radiation Health Unit.
Endorsed radiographer
A licensed diagnostic radiographer approved by the Director
of Radiation Health to assess knowledge or practical skill
competencies.
To become endorsed the radiographer must be licensed,
registered and hold a Certificate IV in Training and
Assessment and apply directly to the Director of Radiation
Health.
Richard S. Sullivan
http://www.reproline.jhu.
edu/english/6read/6train
ing/cbt/sp601web.pdf
Radiation Health Unit
correspondence
Radiation Health
Image assessment form
Form used by radiographic advisor to provide feedback on XO
imaging performance.
Facility manager
The person in the position responsible for the management of
operational and clinical services at the QH facility.
Frequency of practice
A term used to describe the number of times and the time
lapsed between when a task is performed. It directly relates to
the competence level at which that task will be performed.
Mentorship
A less formal relationship between mentor and mentee which
commonly occurs as part of formal supervision. It involves a
radiographic advisor as mentor and x-ray operator as mentee.
This long term working relationship is for the exchange of
ideas, advice, and feedback. The mentor imparts knowledge,
skills and attitudes necessary for radiography, as well as
assisting the mentee to assess their own strengths and
weaknesses in medical imaging activities.
Further reading:
http://www.mhcc.org.au/
documents/Staff%20De
velopment%20Guide/C
h%208%20Supervision.pdf
Primary employment
XO staff have another role within QH other than their imaging
role. This other role is deemed to be their primary
employment as it is performed more regularly than their XO
duties.
LO framework report
http://qheps.health.qld.g
ov.au/cass_radiology/ab
out_us/projects/licensed
_ops/documents/lo_final
_report.pdf
Radiation safety and
protection plan (RSPP)
A Health Service District plan for the practice for which a
possession licensee is allowed to possess a radiation source
under the licence.
Radiation safety officer
(RSO)
Under the Radiation Safety Act 1999 a possession licensee
must ensure, whenever a practice is being carried out, that a
person has been appointed as, and is performing the
functions of, a radiation safety officer for the practice.
A radiation safety officer is an individual who has:
Version No.: 12.0; Effective From: <date>
<insert information security classification>
http://www.sla.org/pdfs/
mentorsh.pdf
Queensland Parliament
http://www.legislation.ql
d.gov.au/LEGISLTN/CU
RRENT/R/RadiatSafA9
9.pdf
Radiation Health
http://www.health.qld.go
v.au/radiationhealth/doc
uments/29471.pdf
Page 3 of 5
Printed copies are uncontrolled
Queensland Health: X-ray Operator Services Policy
Term
Definition/Explanation/Details

a working knowledge of the legislation, guidelines, codes
of practice and standards

knowledge and skills in measuring and monitoring
radiation and interpreting radiation measurements

knowledge and skills in applying radiation safety and
protection principles

knowledge of the biological effects of radiation

possession of a radiation safety officer certificate
Source
Radiographic advisor (RA)
A diagnostic radiographer (usually from within the District)
who is appointed as the main point of contact for each XO.
Their duties include the overseeing of XO services at the
nominated sites, including the facilitation of relevant training
and support as well as assisting in the annual competency
assessment of XOs at those sites.
Clinical and Statewide
Services
http://qis.health.qld.gov.
au/DocumentManagem
ent/Default.aspx?Docu
mentID=26884
Statement of Attainment
Document required for trainee licence application. It provides
evidence of theoretical knowledge attainment.
Radiation Health
Statewide Medical Imaging
Support Services (SMISS)
Statewide Medical Imaging Support Services is one of the
services supported by Radiology Support. Radiology support
is one of the seven branches of Clinical and Statewide
Services. SMISS provides medical imaging support services
to all Queensland public hospitals.
Radiology Support
http://qheps.health.qld.g
ov.au/cass_radiology/ab
out_us/smiss/smiss.htm
Supervision
It is broadly defined as a working alliance between two staff
members where the primary intention of the interaction is to
enhance the knowledge, skills and attitudes of at least one
staff member. In this instance it focuses primarily on practice
issues, rather than broader supervision, staff development
and/or line management issues.
Face-to-face supervision is the preferred method of delivery
wherever possible and a component of supervision should
remain face-to-face. However the geographical dispersion of
staff throughout the state implies that supervision by e-mail,
videoconferencing or teleconferencing has an important place
in ensuring access to supervisors, especially in providing
urgent access in crises.
Supervision agreement
Trainee use licence
A written agreed statement of mutual understanding about the
schedule of XO supervision and training that shall be
provided. The contents are to be agreed on by the XO, RA
and XO’s facility manager.
Agreements are subject to unforeseen circumstances (eg
changes in workload, duties or workplace location) and are to
be renegotiated annually.
A licence type issued under the Radiation Safety Act on
demonstration to the chief executive that the applicant has the
knowledge of diagnostic radiography applicable to their
licence scope. This licence allows the licensee to partake in
practical training without the need for the presence, and
personal supervision, of a use licensee.
Version No.: 12.0; Effective From: <date>
<insert information security classification>
Practice Supervision in
Allied Mental
Health Policy
HR policy G5
http://www.health.qld.go
v.au/qhpolicy/docs/pol/q
h-pol-192.pdf
Practice Supervision in
Allied Mental
Health Policy
HR policy G5
http://www.health.qld.go
v.au/qhpolicy/docs/pol/q
h-pol-192.pdf
Radiation Health
http://www.health.qld.go
v.au/radiationhealth/doc
uments/c_ecompetenci
es.pdf
Page 4 of 5
Printed copies are uncontrolled
Queensland Health: X-ray Operator Services Policy
Term
Definition/Explanation/Details
Source
Use licence
A licence, issued under section 62 of the Radiation Safety Act
1999, to use a radiation source to carry out a radiation
practice.
Queensland Parliament
http://www.legislation.ql
d.gov.au/LEGISLTN/CU
RRENT/R/RadiatSafA9
9.pdf
The following licence types are available:
X-ray operator (XO)
(previously known as
licensed operator or LO)

Chest and extremities

Chest and extremities (rural and remote - extended)

Chest and extremities (rural and remote - medical
practitioner)
Persons who are permitted to use plain film diagnostic x-ray
equipment to perform a limited range of plain film diagnostic
radiography, but who do not have formal qualifications in
diagnostic radiography. Also known as licensed operator
Version No.: 12.0; Effective From: <date>
<insert information security classification>
Radiation Health
http://www.health.qld.go
v.au/radiationhealth/doc
uments/c_ecompetenci
es.pdf
http://www.health.qld.go
v.au/radiationhealth/xra
y/default.asp
Radiation Health
http://www.health.qld.go
v.au/radiationhealth/xra
y/default.asp
Page 5 of 5
Printed copies are uncontrolled